Provider Demographics
NPI:1689000739
Name:GROTH, MARY KATHRYN (BA, LADC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:GROTH
Suffix:
Gender:F
Credentials:BA, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 5TH AVE NE APT 306
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-2545
Mailing Address - Country:US
Mailing Address - Phone:320-630-0440
Mailing Address - Fax:
Practice Address - Street 1:1001 5TH AVE NE APT 306
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-2545
Practice Address - Country:US
Practice Address - Phone:320-630-0440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303697101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)